Nursing assessments in the inpatient geriatric population

Thorough assessment is essential in caring for the institutionalized elderly who have difficulty with urine control. The assessment should include a physical examination, a functional assessment, and an evaluation of the environment. The physical examination should be completed in a timely fashion after incontinence develops in order to rule out treatable causes of urine loss. The examination includes a health history and physical examination, with special attention being given to the genitourinary system. A urine specimen should be obtained during the examination to rule out bladder infection. The functional assessment of the patient is one of the most important aspects of the patient assessment. This is particularly true for elderly inpatients because much of the incontinence found in nursing homes is attributable to functional deficits. The functional assessment should address the history of the patient's incontinence, the patient's cognitive abilities and potential for participating in continence care, the patient's mobility, and the patient's abilities related to activities of daily living. Deficits in any of these areas may contribute to or cause urinary incontinence. In addition to the physical examination and functional assessment of the patient, the environment should be evaluated. The visibility, location, and structure of the toileting facilities can serve to either promote or impair urine control. In addition to the physical facilities provided, the overall nursing care approach may foster or hinder the patient's ability to maintain urinary continence. Nursing assessment that addresses these three areas will provide information that is needed to develop a nursing care plan that will maximize the patient's potential for urine control.     

Chemotherapy in the geriatric population

The population in America is aging, and the number of older adults who develop cancer continues to grow. Gerontologic considerations in the delivery of health care become increasingly more important as a result of these population trends. Factors such as physiologic age-related changes, comorbid conditions, and the incidence of polypharmacy contribute to the challenges of administering chemotherapy to older patients with cancer. Age-related physiologic changes, including alterations in the gastrointestinal system, renal system, body composition, and hematopoiesis, impact patients' ability to tolerate standard doses of chemotherapy. In addition, these changes increase the likelihood of developing severe toxicities. Comorbid conditions confound the side effects of chemotherapy, and the use of multiple medications places older patients with cancer at increased risk for developing drug interactions. Older patients with cancer may be more susceptible to developing toxicities from chemotherapy, and these toxicities may be more severe. When healthcare professionals follow age-appropriate standards of oncology care, chemotherapy can be safely and effectively administered to older patients with cancer. Oncology nurses play a crucial role in assessing for potential complications and managing toxicities. Incorporating geriatric care into oncology nurses' daily practice ensures quality care for older patients with cancer.     

Measuring quality of care with an inpatient elderly population. The geriatric resource nurse model

Nurses provide health services to an increasing number of older adults in acute care settings. Acute care nurses are committed to giving patients the highest quality care while recognizing the importance of delivering care in a cost-effective manner. In this study, a unit-based, nurse-centered geriatric program is evaluated. The program is designed to enhance the knowledge and skill of staff nurses in providing care to elderly patients. Both quantitative and qualitative methods are used to assess geriatric resource nurses' (GRNs) influence on quality and cost outcomes of the elderly participants. Patients age 65 years and older were randomly selected from two general medical units of a major academic tertiary care center in the southeastern United States. Data were collected during an 18-month period in 1996 and 1997. A total of 129 participants provided data for quantitative analysis. A subset of 34 participants (17 from the unit where GRNs were on staff and 17 from a control unit) was interviewed about their experience during hospitalization. This information was analyzed for common themes and trends using appropriate qualitative techniques. Demographic variables and common measures of illness severity and complexity showed comparable patient populations on the two units. However, results of quantitative analyses indicated significant differences between groups on admission for several of the health status measures. Participants on the unit without GRNs were found to have more problems with pain, incontinence, and mobility. Administrative measures showed the number of patients readmitted to the hospital within 31 days of discharge and the length of stay associated with this initial readmission were significantly lower on the unit with GRNs. The use of vest-type physical restraints was also less frequent on this unit. Elderly patients in both groups indicated they have special needs related to normal aging changes and chronic illnesses, resulting in higher levels of fragility and decreased energy reserves. They identified specific functional areas for which help was needed. These include assistance with bathing, eating, sleeping, mobility, and elimination. Fewer participants on the intervention unit reported decline in activities of daily living (ADL) function during hospitalization than did control participants. Participants in both groups stressed the importance of nurses' demonstrating understanding and caring when working with older individuals.     

The impact of medical issues in inpatient geriatric psychiatry

At an advanced age, serious medical and psychiatric illnesses frequently coalesce. Often, the need for admission to inpatient geriatric psychiatric care arises from coexisting medical problems. While cognitive and behavioral interventions are important, the complexity of physical comorbidities usually becomes the focus of hospitalization and requires intensive medical treatments. This paper describes adaptations made in one metropolitan geriatric psychiatry unit in order to better treat complex patients who experience both medical and psychiatric illness. The need for all members of the interdisciplinary team to expand their practice and the importance of complementary approaches of psychiatry and medicine are emphasized.     

Medication education program in an inpatient geriatric rehabilitation unit

All patients admitted during a 6-month period to an inpatient geriatric rehabilitation unit were started on a medication education program incorporated into the rehabilitation program and utilizing existing staff. Patients were evaluated at admission, discharge, 90-day, and 1 year follow-up, using an 8-point medication knowledge scale. Of the 62 patients included in this study, at discharge 35 (group I, mean age 75.9) knew their medications and went home, 10 (group II, mean age 76.8) did not know their medications and went home, and 17 (group III, mean age 79.3) did not go home, whether they knew their medications or not. Mean length of stay (days) was: group I-30.9; group II-38.9; group III-33.3. This study describes a program for teaching an inpatient geriatric age group population self-medication management.     

Community-acquired infections in the geriatric trauma population

The incidence of community-acquired infections (CAs) and their relationship to the incidence of nosocomial infections (NI), to our knowledge, is unknown in elderly trauma patients. We prospectively collected data on 380 patients > or =65 years of age who were admitted >48 h to our trauma center over a 2-year period. One hundred seventy-seven patients (47%) developed an infection. A total of 147 (39%) patients were diagnosed with an NI, and 67 (18%) were diagnosed with a CA. Of the 67 patients with CA, 37 (55%) went on to develop an NI. Patients with the combination of CA and NI had the greatest mean ICU (28.6 days) and hospital length of stay (38.2 days). Mortality was increased significantly in patients with the combination of CA and NI (27%). Respiratory and genitourinary infections were the most common CA. Patients with respiratory CAs accounted for the greatest proportion of NIs. Thus, community-acquired and nosocomial infections significantly increase morbidity and mortality in elderly patients post-injury. Patients who present with a CA are at increased risk of acquiring an NI, which is associated with the most significant increase in length of stay and mortality.     

Validity of 3 physical performance measures in inpatient geriatric rehabilitation

OBJECTIVE: To evaluate the construct validity and the responsiveness of 3 measures of physical performance measures as outcome measures for frail older persons. DESIGN: Pre-post design with measures at admission and discharge. SETTING: Three inpatient geriatric rehabilitation programs. PARTICIPANTS: Fifty-two subjects (35 women, 17 men; age, 80+/-8y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Physical performance measures were Timed Up & Go (TUG) test, two-minute walk test (2MWT), and functional reach. Functional status was measured with the FIM instrument and the Modified Barthel Index. RESULTS: The TUG and 2MWT scores differed significantly in groups of patients using different ambulatory aids (P=.006), whereas no such difference was observed for the functional reach (P=.40). The correlations between the TUG test and FIM and between the 2MWT and FIM were -.59 and .59 (P<.001), respectively, at admission, and -.42 and .47 (P< or =.04), respectively, at admission and discharge. The correlations between functional reach and the FIM were not significant (P> or =.09). Standardized response means were 1.1 for the TUG, 0.7 for the 2MWT, and 0.5 for functional reach. CONCLUSIONS: The TUG test and 2MWT are valid and responsive outcome measures in older persons participating in geriatric rehabilitation. Functional reach was a moderately responsive outcome measure but did not consistently reflect ambulatory or functional status.     

New graduate orientation program in a geriatric psychiatric inpatient setting

With the geriatric population increasing, so will their needs for mental health care. However, attracting nurses to work with mentally ill older adults can be challenging. This article describes and illustrates methods successfully used by one hospital to attract, orient, and mentor new graduate nurses to work in geropsychiatric nursing--the New Graduate Residency Program (NGRP). The importance of supportive collaborative roles within nursing leadership staff is emphasized. Although the NGRP is a viable option for meeting the needs of older patients, additional strategies are needed to increase the numbers of geropsychiatric nurses overall, and these are discussed.     

Special considerations for the geriatric population

Health care providers can be the eyes and ears of patient safety when it comes to medication administration. Simply asking questions about the medication and dose can avert a drug-drug interaction or save the patient's life. When caring for the older adult, question if the drug is right for this patient; if the dose is correct or if it has been adjusted to start at a lower dose; if the patient has renal or kidney dysfunctions that may further affect dosing; and if the patient has been thoroughly assessed for swallowing, cognitive, and physical disorders [22]. Remember that confusion may be an early sign of an adverse drug event. Health care providers can be the first line of defense in reducing adverse medication events in the older adult.     

End-of-life care in the critically ill geriatric population

As the geriatric population in the United States increases and better management of chronic diseases improves survival, more elderly will become critically ill and potentially require treatment in an intensive care unit (ICU). Dan Callahan has written, "... we will live longer lives, be better sustained by medical care, in return for which our deaths in old age are more likely to be drawn out and wild." Although no health care provider hopes for a drawn out and wild death for elderly patients, many geriatric persons will succumb to disease and die after having chosen and received ICU care. Recent data suggest that, on average, 11% of Medicare recipients spend more that 7 days in the ICU within 6 months before death.     

Physiotherapists’ accounts of their clients in geriatric inpatient rehabilitation

This article aims to describe how physiotherapists working with frail older people talk about their clients. Semi‐structured qualitative interviews with physiotherapists (n = 11) were audio recorded, transcribed and analysed using discourse analysis. Two accounts were identified: (i) older adults as recipients of a treatment intervention at the rehabilitation centre, with the dimensions ‘a focus on physical impairments’ and ‘a focus on social needs’ and (ii) older adults as partners in an exercise intervention to support their everyday living at home. Older adults’ everyday living context was not considered in the approach where, in an isolated and objectified manner, the physiotherapists focused on physical impairments. Placing great emphasis on the clients’ social needs in turn implied passive treatments. In both instances the physiotherapists’ activities were focused on the present, that is, the time of the clients’ stay at the rehabilitation facility, rather than on their everyday challenges at home. These aspects were taken into accounts to a greater extent when older adults were positioned as partners and functional limitations were contemplated in relation to domestic daily living.     

Reinforcing organizationwide pressure ulcer reduction on high-risk geriatric inpatient units

Skin care and pressure ulcer prevention programs abound, although their content varies and their outcomes are often difficult to quantify. This article describes 2 complementary programs, their quality improvement processes, and a variety of ways of measuring their success. The first program was broad in scope, emphasizing system-wide changes in administration and coordination of resources, while the second focused on nursing education on high-risk units. These 2 approaches could be adapted for use in any health care setting.